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Cetera GE, Punzi MC, Merli CEM, Vercellini P. Menstrual products: culprits or bystanders in endometriosis and adenomyosis pathogenesis? Arch Gynecol Obstet 2024:10.1007/s00404-024-07713-w. [PMID: 39198282 DOI: 10.1007/s00404-024-07713-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 08/19/2024] [Indexed: 09/01/2024]
Abstract
Products that may reduce menstrual flow from the endometrial cavity to the vagina (i.e. tampons and menstrual cups) could facilitate retrograde menstruation and the spillage of blood into the myometrium, two mechanisms which could be major determinants in endometriosis and adenomyosis pathogenesis. The aim of this narrative review is to summarize the evidence regarding the mechanical role menstrual products may have in the pathogenesis of these two conditions. Evidence in this regard is inconclusive. While Darrow and colleagues observed that 14 or more years of tampon use were associated with endometriosis (OR 3.6; 95% CI, 1.04-13.5); in Meaddough and colleagues' retrospective study, the percentage of women using pads only was significantly higher among those with endometriosis than among those without the condition (31% vs 22%). Three further groups failed to find an association between endometriosis/adenomyosis and any type of menstrual product. The only case that may be considered as a sort of proof-of-concept of the association between products potentially reducing anterograde menstrual flow and endometriosis was reported by Spechler and colleagues, who described the case of a 41 year-old who developed endometriosis after having used a menstrual cup on a regular basis. However, the number of studies on the subject is scarce, study populations are exiguous and a greater attention to temporality of endometriosis onset in relation to when women started habitually using a specific menstrual product is needed. Confounding variables including type and quantity of endocrine disruptors contained in menstrual products should also be addressed. At the present moment, no recommendation can be provided on the safety of one type of menstrual product compared to another.
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Affiliation(s)
- G E Cetera
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Academic Center for Research On Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
| | - M C Punzi
- Business-Society Management Department, Rotterdam School of Management, Erasmus University, Rotterdam, the Netherlands
| | - C E M Merli
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - P Vercellini
- Gynecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Academic Center for Research On Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy
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2
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Tindal K, Cousins FL, Ellery SJ, Palmer KR, Gordon A, Filby CE, Gargett CE, Vollenhoven B, Davies-Tuck ML. Investigating Menstruation and Adverse Pregnancy Outcomes: Oxymoron or New Frontier? A Narrative Review. J Clin Med 2024; 13:4430. [PMID: 39124698 PMCID: PMC11312851 DOI: 10.3390/jcm13154430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/19/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
Not discounting the important foetal or placental contribution, the endometrium is a key determinant of pregnancy outcomes. Given the inherently linked processes of menstruation, pregnancy and parturition with the endometrium, further understanding of menstruation will help to elucidate the maternal contribution to pregnancy. Endometrial health can be assessed via menstrual history and menstrual fluid, a cyclically shed, easily and non-invasively accessible biological sample that represents the distinct, heterogeneous composition of the endometrial environment. Menstrual fluid has been applied to the study of endometriosis, unexplained infertility and early pregnancy loss; however, it is yet to be examined regarding adverse pregnancy outcomes. These adverse outcomes, including preeclampsia, foetal growth restriction (FGR), spontaneous preterm birth and perinatal death (stillbirth and neonatal death), lay on a spectrum of severity and are often attributed to placental dysfunction. The source of this placental dysfunction is largely unknown and may be due to underlying endometrial abnormalities or endometrial interactions during placentation. We present existing evidence for the endometrial contribution to adverse pregnancy outcomes and propose that a more comprehensive understanding of menstruation can provide insight into the endometrial environment, offering great potential value as a diagnostic tool to assess pregnancy risk. As yet, this concept has hardly been explored.
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Affiliation(s)
- Kirstin Tindal
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC 3168, Australia (C.E.G.); (M.L.D.-T.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia; (K.R.P.); (B.V.)
- NHMRC Centre for Research Excellence (CRE) in Stillbirth, Brisbane, QLD 4101, Australia;
| | - Fiona L. Cousins
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC 3168, Australia (C.E.G.); (M.L.D.-T.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia; (K.R.P.); (B.V.)
| | - Stacey J. Ellery
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC 3168, Australia (C.E.G.); (M.L.D.-T.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia; (K.R.P.); (B.V.)
| | - Kirsten R. Palmer
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia; (K.R.P.); (B.V.)
- Women’s and Newborn Program, Monash Health, Clayton, VIC 3168, Australia
| | - Adrienne Gordon
- NHMRC Centre for Research Excellence (CRE) in Stillbirth, Brisbane, QLD 4101, Australia;
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia
| | - Caitlin E. Filby
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia; (K.R.P.); (B.V.)
| | - Caroline E. Gargett
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC 3168, Australia (C.E.G.); (M.L.D.-T.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia; (K.R.P.); (B.V.)
| | - Beverley Vollenhoven
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia; (K.R.P.); (B.V.)
- Women’s and Newborn Program, Monash Health, Clayton, VIC 3168, Australia
| | - Miranda L. Davies-Tuck
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC 3168, Australia (C.E.G.); (M.L.D.-T.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia; (K.R.P.); (B.V.)
- NHMRC Centre for Research Excellence (CRE) in Stillbirth, Brisbane, QLD 4101, Australia;
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Viganò P, Caprara F, Giola F, Di Stefano G, Somigliana E, Vercellini P. Is retrograde menstruation a universal, recurrent, physiological phenomenon? A systematic review of the evidence in humans and non-human primates. Hum Reprod Open 2024; 2024:hoae045. [PMID: 39055487 PMCID: PMC11272177 DOI: 10.1093/hropen/hoae045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 06/17/2024] [Indexed: 07/27/2024] Open
Abstract
STUDY QUESTION What are the quantitative, qualitative, and temporal patterns of retrograde mentruation? SUMMARY ANSWER The extreme quantitative and qualitative heterogeneity of the available studies prevents the definitive conclusion that retrograde menstruation is a universal and consistent phenomenon during the reproductive period. WHAT IS KNOWN ALREADY Retrograde menstruation has been defined as a universal, physiological phenomenon that occurs similarly in about 90% of menstruators during the reproductive period. However, uncertainties still exist in terms of the event frequency, total amount, and cellular composition of retrograde menstruation and the differences between individuals with versus those without endometriosis. STUDY DESIGN SIZE DURATION Two systematic reviews were performed, one for human studies, and one for non-human primate studies. We retrieved studies from the PubMed and Embase databases published between 1 January 1980 and 1 November 2023. Studies published in the English language were included and identified using a combination of MeSH terms. References from relevant publications were systematically screened and further articles were identified using PubMed's 'similar articles' and 'cited by' functions. PARTICIPANTS/MATERIALS SETTING METHODS Results were reported in accordance with the PRISMA guidelines. Studies that did not report original data or provided a review of the field were excluded. Bias analysis was completed for each included human study by using the Newcastle-Ottawa scoring system. MAIN RESULTS AND THE ROLE OF CHANCE Fifteen studies were finally included in the human systematic review, mostly with limited sample sizes. The macroscopic visualization of blood in PF during menses was reported with a frequency ranging from 9% to 100%. A prevalence of endometrial cells detected in peritoneal fluid ranging from 8% to 75% was reported in the various studies. Controversial findings were reported in relation to patients with endometriosis. Retrograde menstruation has been evaluated cross-sectionally on single occasions, and no information is available on the course of the phenomenon within an entire cycle and between subsequent cycles. Two studies were included in the non-human primate systematic review; one of them showed that retrograde menstruation was observed more frequently in baboons with naturally occurring endometriosis (83%) than in those with a normal pelvis (51%). LIMITATIONS REASONS FOR CAUTION In humans, peritoneal fluid has often been collected at different cycle phases and not systematically during menstruation. The indication for laparoscopy was not always clear for all participants. A wide variety of methods were used to detect endometrial cells, including cytological staining, cell block analysis, immunocytochemistry, and various methods of cell culture. WIDER IMPLICATION OF THE FINDINGS The idea that almost all women experience retrograde menstruation regularly and similarly during their reproductive life is currently unsubstantiated. It is an academic notion accepted uncritically. Development of endometriosis may derive from differences in the frequency or severity of the event. STUDY FUNDING/COMPETING INTERESTS The review was partially funded by Italian Ministry of Health-Current Research IRCCS. P.Vi. serves as co-editor in Chief of Journal of Endometriosis and Uterine Disorders. E.S. serves as Editor in Chief of Human Reproduction Open and discloses research grants from Ferring, Ibsa, Gedeon Richter, and Theramex, and honoraria from Ibsa and Gedeon Richter. P.Ve. serves as Associate Editor for Human Reproduction Open; is a member of the Editorial Board of the Journal of Obstetrics and Gynaecology Canada, of the Italian Journal of Obstetrics and Gynaecology, and of the International Editorial Board of Acta Obstetricia et Gynecologica Scandinavica; has received royalties from Wolters Kluwer for chapters on endometriosis management in the clinical decision support resource UpToDate; and maintains both a public and private gynecological practice. All other authors declare they have no conflict of interest. REGISTRATION NUMBER N/A.
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Affiliation(s)
- Paola Viganò
- Infertility Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Caprara
- Department of Clinical Sciences and Community Health, Academic Center for Research on Adenomyosis and Endometriosis, Università degli Studi di Milano, Milan, Italy
| | - Francesca Giola
- Department of Clinical Sciences and Community Health, Academic Center for Research on Adenomyosis and Endometriosis, Università degli Studi di Milano, Milan, Italy
| | - Giorgia Di Stefano
- Infertility Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Edgardo Somigliana
- Infertility Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Academic Center for Research on Adenomyosis and Endometriosis, Università degli Studi di Milano, Milan, Italy
| | - Paolo Vercellini
- Infertility Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Academic Center for Research on Adenomyosis and Endometriosis, Università degli Studi di Milano, Milan, Italy
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Vercellini P, Piccini M, Caprara F, Cetera GE, Viganò P, Somigliana E. Potential anatomical determinants of retrograde menstruation: a comprehensive narrative review. Reprod Biomed Online 2024; 49:104345. [PMID: 39137508 DOI: 10.1016/j.rbmo.2024.104345] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 05/30/2024] [Accepted: 06/17/2024] [Indexed: 08/15/2024]
Abstract
A century ago, Sampson identified three uterine anatomical structures that may determine the amount of retrograde menstruation and the likelihood of the development of endometriosis: the cervix, the intramural portion of the fallopian tubes, and the myometrium. Critical appraisal was undertaken of data published over the last 40 years on the potential effect of the characteristics of these three anatomical variables on the risk of endometriosis. There is some evidence to support the pathogenic role of the diameter of the cervical canal, stenosis of internal or external orifices, and stiffness of cervical tissue. One study showed a significant association between the morphology of the intramural tubal tract and the frequency of endometriosis. A large body of evidence points to abnormalities of the myometrial structure as the anatomical aberration most consistently associated with endometriosis. These abnormalities have largely been interpreted as signs of early-onset adenomyosis, which may precede endometriosis and even lead to its development by increasing the amount of retrograde menstruation. Future research should aim to verify whether a positive relationship exists between the substantially increased number of ovulatory menses occurring in the decade following menarche, the development of anatomical myometrial abnormalities, changes in the amount of retrograde menstruation over time, and the risk of endometriosis.
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Affiliation(s)
- Paolo Vercellini
- Academic Centre for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Martina Piccini
- Academic Centre for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milan, Italy
| | - Francesca Caprara
- Academic Centre for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milan, Italy
| | - Giulia Emily Cetera
- Academic Centre for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Viganò
- Academic Centre for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Edgardo Somigliana
- Academic Centre for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Watson C. Surge in endometriosis research after decades of underfunding could herald new era for women's health. Nat Med 2024; 30:315-318. [PMID: 38321217 DOI: 10.1038/s41591-024-02795-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Clare Watson
- Freelance science journalist, Wollongong, Australia
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Vercellini P, Bandini V, Viganò P, Di Stefano G, Merli CEM, Somigliana E. Proposal for targeted, neo-evolutionary-oriented, secondary prevention of early-onset endometriosis and adenomyosis. Part I: pathogenic aspects. Hum Reprod 2024; 39:1-17. [PMID: 37951243 PMCID: PMC10876119 DOI: 10.1093/humrep/dead229] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 10/17/2023] [Indexed: 11/13/2023] Open
Abstract
The potential for repeated ovulation and menstruation is thought to have provided a Darwinian advantage during the Palaeolithic. Reproductive conditions remained relatively stable until the pre-industrial era, characterized by late menarche, very young age at first birth, multiple pregnancies, and prolonged periods of lactational amenorrhoea. For hundreds of thousands of years, menstruators experienced few ovulatory cycles, even though they were genetically adapted to ovulate and menstruate every month. In the post-industrial era, the age at menarche gradually declined, the age at first birth progressively increased, and breastfeeding became optional and often of short duration. This created a mismatch between genetic adaptation and socio-environmental evolution, so that what was initially a probable reproductive advantage subsequently contributed to increased susceptibility to diseases associated with lifetime oestrogen exposure, such as ovarian, endometrial and breast cancer and, hypothetically, also those associated with the number of ovulatory menstruations, such as endometriosis and adenomyosis. The incidence of endometriosis shows a steep and progressive increase around the age of 25 years, but given the consistently reported delay in diagnosis, the actual incidence curve should be shifted to the left, supporting the possibility that the disease has its roots in adolescence. This raises the question of whether, from an evolutionary point of view, anovulation and amenorrhoea should not still be considered the physiological state, especially in the postmenarchal period. However, an increase in the frequency of endometriosis in recent decades has not been demonstrated, although this deserves further epidemiological investigation. In addition, as endometriosis occurs in a minority of individuals exposed to retrograde menstruation, other important pathogenic factors should be scrutinised. Research should be resumed to explore in more detail the transtubal reflux of not only blood, but also endometrial cells, and whether they are systematically present in the peritoneal fluid after menstruation. If repetitive ovulatory menstruation during the early reproductive years is shown to increase the risk of endometriosis and adenomyosis development and progression in susceptible individuals, hormonal interventions could be used as secondary prevention in symptomatic adolescents.
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Affiliation(s)
- Paolo Vercellini
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Veronica Bandini
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
| | - Paola Viganò
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Giorgia Di Stefano
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Academic Centre for Research on Adenomyosis and Endometriosis, Università degli Studi, Milano, Italy
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
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7
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Tindal K, Filby CE, Gargett CE, Cousins F, Palmer KR, Vollenhoven B, Davies-Tuck M. Endometrial Origins of Stillbirth (EOS), a case-control study of menstrual fluid to understand and prevent preterm stillbirth and associated adverse pregnancy outcomes: study protocol. BMJ Open 2023; 13:e068919. [PMID: 37433731 DOI: 10.1136/bmjopen-2022-068919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
INTRODUCTION Current research aimed at understanding and preventing stillbirth focuses almost exclusively on the role of the placenta. The underlying origins of poor placental function leading to stillbirth, however, remain poorly understood. There is evidence demonstrating that the endometrial environment in which the embryo implants impacts not only the establishment of pregnancy but also the development of some pregnancy outcomes. Menstrual fluid has recently been applied to the study of menstrual disorders such as heavy menstrual bleeding or endometriosis, however, it has great potential in the study of adverse pregnancy outcomes. This study aims to identify differences in menstrual fluid and menstrual cycle characteristics of women who have experienced preterm stillbirth and other associated adverse pregnancy outcomes, compared with those who have not. The association between menstrual fluid composition and menstrual cycle characteristics will also be determined. METHODS AND ANALYSIS This is a case-control study of women who have experienced a late miscarriage, spontaneous preterm birth or preterm stillbirth or a pregnancy complicated by placental insufficiency (fetal growth restriction or pre-eclampsia), compared with those who have had a healthy term birth. Cases will be matched for maternal age, body mass index and gravidity. Participants will not currently be on hormonal therapy. Women will be provided with a menstrual cup and will collect their sample on day 2 of menstruation. Primary exposure measures include morphological and functional differences in decidualisation of the endometrium (cell types, immune cell subpopulations and protein composition secreted from the decidualised endometrium). Women will complete a menstrual history survey to capture menstrual cycle length, regularity, level of pain and heaviness of flow. ETHICS AND DISSEMINATION Ethics approval was obtained from Monash University Human Research Ethics Committee (27900) on 14/07/2021 and will be conducted in accordance with these conditions. Findings from this study will be disseminated through peer-reviewed publications and conference presentations.
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Affiliation(s)
- Kirstin Tindal
- The Ritchie Centre at Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University School of Clinical Sciences at Monash Health, Clayton, Victoria, Australia
| | - Caitlin E Filby
- Faculty of Medicine Nursing and Health Sciences, Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Caroline E Gargett
- The Ritchie Centre at Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University School of Clinical Sciences at Monash Health, Clayton, Victoria, Australia
| | - Fiona Cousins
- The Ritchie Centre at Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University School of Clinical Sciences at Monash Health, Clayton, Victoria, Australia
| | - Kirsten Rebecca Palmer
- Department of Obstetrics and Gynaecology, Monash University School of Clinical Sciences at Monash Health, Clayton, Victoria, Australia
- Monash University Women's Health Research Program, Melbourne, Victoria, Australia
| | - Beverley Vollenhoven
- Department of Obstetrics and Gynaecology, Monash University School of Clinical Sciences at Monash Health, Clayton, Victoria, Australia
- Monash University Women's Health Research Program, Melbourne, Victoria, Australia
| | - Miranda Davies-Tuck
- The Ritchie Centre at Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University School of Clinical Sciences at Monash Health, Clayton, Victoria, Australia
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8
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Ogawa K, Khan KN, Kuroboshi H, Koshiba A, Shimura K, Tajiri T, Fumino S, Fujita H, Okubo T, Fujiwara Y, Horiguchi G, Teramukai S, Fujishita A, Itoh K, Guo SW, Kitawaki J, Mori T. Is neonatal uterine bleeding responsible for early-onset endometriosis? Reprod Biol Endocrinol 2023; 21:56. [PMID: 37337237 DOI: 10.1186/s12958-023-01099-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 05/07/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND It has been hypothesized that the origin of early-onset endometriosis could be from endometrial mesenchymal stem cells (eMSCs) in neonatal uterine blood (NUB). There is no information on the possible mechanistic basis linking an association between NUB/neonatal endometrium and development of early-onset endometriosis. In this study we performed a series of experiments to clarify the mechanistic link between NUB and/or neonatal endometrium and development of early-onset endometriosis. METHODS We retrospectively collected postmortem neonatal endometria (n = 15) and prospectively collected NUB (n = 18) of female babies for the analysis of different biological markers including eMSCs. Immunohistochemical analysis of neonatal endometria was performed to examine the expression patterns of ovarian steroid receptors (ER/PGR), decidualization (prolactin, IGFBP1), pre-decidualization (Glycodelin A, α-SMA), proliferation (Ki-67 index), vascularity (CD31 + cells), immunocompetent CD68+, CD45+, CD56 + cells and some putative markers of eMSCs. Cell transfer method and immunocytochemistry were used to investigate the eMSCs and/or endometrial cells in NUB. RESULTS Immunohistochemical analysis of postmortem neonatal endometria revealed variable staining response to ER/PGR, decidual markers, and substantial proliferative and angiogenic activity. A moderate to strong immunoexpression of Glycodelin-A was found in both neonatal and adult endometria. The tissue infiltration of CD56+, CD45 + and CD68 + immunocompetent cells was significantly low in neonatal endometria than that in adult endometria (p = 0.0003, p < 0.0001, p = 0.034, respectively). No eMSCs or even endometrial cells were detected in NUB. However, a variable expression of some phenotypes of eMSCs (CD90/CD105) was found in neonatal endometria. CONCLUSIONS Based on our serial experiments we did not find any supporting evidence for the role of NUB in early-onset endometriosis. Neonatal endometria showed variable expression of ovarian steroid receptors, decidualization, and a substantial amount of proliferative and angiogenic activity. As an alternative mechanism, a significantly less tissue accumulation of immunocompetent cells in neonatal endometria may explain the survival of ER + and PGR + cells should they make entry into the pelvis and consequent development of early endometriosis with the onset of ovarian function. Future study with large sample size and application of modified technological tools is warranted to test the NUB hypothesis and to clarify their biological or clinical significance. TRIAL REGISTRATION not applicable.
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Affiliation(s)
- Kanae Ogawa
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Khaleque N Khan
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
- The Clinical and Translational Research Center, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Haruo Kuroboshi
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akemi Koshiba
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Koki Shimura
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tatsuro Tajiri
- Department of Pediatric Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Pediatric Surgery, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shigehisa Fumino
- Department of Pediatric Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroyuki Fujita
- Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
| | - Tomoharu Okubo
- Japanese Red Cross Society Kyoto Daiichi Hospital, Kyoto, Japan
| | | | - Go Horiguchi
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akira Fujishita
- Department of Gynecology, Saiseikai Nagasaki Hospital, Nagasaki, Japan
| | - Kyoko Itoh
- Department of Pathology and Applied Neurobiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sun-Wei Guo
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Jo Kitawaki
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Taisuke Mori
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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9
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Cousins FL, McKinnon BD, Mortlock S, Fitzgerald HC, Zhang C, Montgomery GW, Gargett CE. New concepts on the etiology of endometriosis. J Obstet Gynaecol Res 2023; 49:1090-1105. [PMID: 36746607 PMCID: PMC10946875 DOI: 10.1111/jog.15549] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/30/2022] [Indexed: 02/08/2023]
Abstract
Endometriosis is a serious, chronic disorder where endometrial tissue grows outside the uterus, causing severe pelvic pain and infertility. It affects 11% of women. Endometriosis is a multifactorial disorder of unclear etiology, although retrograde menstruation plays a major role. It has a genetic component with over 40 genetic risk factors mapped, although their mechanism of action is still emerging. New evidence suggests a role for retrograde menstruation of endometrial stem/progenitor cells, now that identifying markers of these cells are available. Recent lineage tracing and tissue clearing microscopy and 3D reconstruction has provided new understanding of endometrial glandular structure, particularly the horizontal orientation and interconnection of basalis glands. New sequencing technologies, particularly whole genome DNA sequencing are revealing somatic mutations, including in cancer driver genes, in normal and eutopic endometrium of patients with endometriosis, as well as ectopic endometriotic lesions. Methylome sequencing is offering insight into the regulation of genes and the role of the environmental factors. Single cell RNA sequencing reveals the transcriptome of individual endometrial cells, shedding new light on the diversity and range of cellular subpopulations of the major cell types present in the endometrium and in endometriotic lesions. New endometrial epithelial organoid cultures replicating glandular epithelium are providing tractable models for studying endometriosis. Organoids derived from menstrual fluid offer a non-invasive source of endometrial tissue and a new avenue for testing drugs and developing personalized medicine for treating endometriosis. These new approaches are rapidly advancing our understanding of endometriosis etiology.
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Affiliation(s)
- Fiona L. Cousins
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVictoriaAustralia
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVictoriaAustralia
| | - Brett D. McKinnon
- Institute for Molecular Biosciences, The University of QueenslandBrisbaneAustralia
| | - Sally Mortlock
- Institute for Molecular Biosciences, The University of QueenslandBrisbaneAustralia
| | - Harriet C. Fitzgerald
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVictoriaAustralia
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVictoriaAustralia
| | - Chenyu Zhang
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVictoriaAustralia
| | - Grant W. Montgomery
- Institute for Molecular Biosciences, The University of QueenslandBrisbaneAustralia
| | - Caroline E. Gargett
- The Ritchie CentreHudson Institute of Medical ResearchClaytonVictoriaAustralia
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVictoriaAustralia
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10
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Fan Y, Lee RWK, Ng XW, Gargett CE, Chan JKY. Subtle changes in perivascular endometrial mesenchymal stem cells after local endometrial injury in recurrent implantation failure. Sci Rep 2023; 13:225. [PMID: 36604485 PMCID: PMC9816312 DOI: 10.1038/s41598-023-27388-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 01/02/2023] [Indexed: 01/07/2023] Open
Abstract
Improvements in reproductive techniques have resulted in the live birth rates from IVF procedures increasing from 5% to approximately 30% in recent decades but has plateaued since. Emerging preclinical and clinical data implicates endometrial receptivity deficiencies in patients with recurrent implantation failure (RIF) as the predominant factor hindering successful implantation. Mechanisms on how local endometrial injury (LEI) improves implantation rates in patients with RIF are currently unknown. We hypothesized that LEI may influence perivascular endometrial mesenchymal stem/progenitor cells (eMSCs) which are thought to regenerate the stromal vascular component of the functional layer every month. Here, we assessed the effect of LEI on the proportion and function of eMSCs present in consecutive LEI biopsies. Consecutive paired mid-luteal phase endometrial biopsies obtained from patients with RIF were digested to single cells and the proportion of SUSD2-expressing cells determined. Growth kinetics and decidualization were compared between the consecutive LEI samples. A mid-luteal LEI altered the decidualization capacity of SUSD2+ eMSCs in women with RIF, but not their proportion or clonogenicity. With the potential of LEI to improve IVF outcomes in women with RIF, additional investigations are needed to understand the impact of the altered decidualization response in eMSCs.
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Affiliation(s)
- Yiping Fan
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore, Singapore. .,Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University Health System, Singapore, Singapore. .,Academic Clinical Program in Obstetrics and Gynaecology, Duke-NUS Medical School, Singapore, Singapore.
| | - Ryan Wai Kheong Lee
- grid.414963.d0000 0000 8958 3388Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Xiang Wen Ng
- grid.414963.d0000 0000 8958 3388Department of Reproductive Medicine, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Caroline E. Gargett
- grid.452824.dThe Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC Australia ,grid.1002.30000 0004 1936 7857Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC Australia
| | - Jerry Kok Yen Chan
- grid.414963.d0000 0000 8958 3388Department of Reproductive Medicine, KK Women’s and Children’s Hospital, Singapore, Singapore ,grid.4280.e0000 0001 2180 6431Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University Health System, Singapore, Singapore ,grid.428397.30000 0004 0385 0924Academic Clinical Program in Obstetrics and Gynaecology, Duke-NUS Medical School, Singapore, Singapore
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11
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Leyendecker G, Wildt L, Laschke MW, Mall G. Archimetrosis: the evolution of a disease and its extant presentation : Pathogenesis and pathophysiology of archimetrosis (uterine adenomyosis and endometriosis). Arch Gynecol Obstet 2023; 307:93-112. [PMID: 35596746 PMCID: PMC9836992 DOI: 10.1007/s00404-022-06597-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/27/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE This article presents a novel concept of the evolution and, thus, the pathogenesis of uterine adenomyosis as well as peritoneal and peripheral endometriosis. Presently, no unifying denomination of this nosological entity exists. METHODS An extensive search of the literature on primate evolution was performed. This included comparative functional morphology with special focus on the evolution of the birthing process that fundamentally differs between the haplorrhine primates and most of the other eutherian mammals. The data were correlated with the results of own research on the pathophysiology of human archimetrosis and with the extant presentation of the disease. RESULTS The term Archimetrosis is suggested as a denomination of the nosological entity. Archimetrosis occurs in human females and also in subhuman primates. There are common features in the reproductive process of haplorrhine primates such as spontaneous ovulation and corpus luteum formation, spontaneous decidualization and menstruation. These have fused Müllerian ducts resulting in a uterus simplex. Following a usually singleton pregnancy, the fetus is delivered in the skull position. Some of these features are shared by other mammals, but not in that simultaneous fashion. In haplorrhine primates, with the stratum vasculare, a new myometrial layer has evolved during the time of the Cretaceous-Terrestrial Revolution (KTR) that subserves expulsion of the conceptus and externalization of menstrual debris in non-conceptive cycles. Hypercontractility of this layer has evolved as an advantage with respect to the survival of the mother and the birth of a living child during delivery and may be experienced as primary dysmenorrhea during menstruation. It may result in tissue injury by the sheer power of the contractions and possibly by the associated uterine ischemia. Moreover, the lesions at extra-uterine sites appear to be maintained by biomechanical stress. CONCLUSIONS Since the pathogenesis of archimetrosis is connected with the evolution of the stratum vasculare, tissue injury and repair (TIAR) turns out to be the most parsimonious explanation for the development of the disease based on clinical, experimental and evolutionary evidence. Furthermore, a careful analysis of the published clinical data suggests that, in the risk population with uterine hypercontractility, the disease develops with a yet to be defined latency phase after the onset of the biomechanical injury. This opens a new avenue of prevention of the disease in potentially affected women that we consider to be primarily highly fertile.
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Affiliation(s)
| | | | - Matthias W. Laschke
- Institut für Klinisch-Experimentelle Chirurgie, Universität des Saarlandes, 66421 Homburg, Germany
| | - Gerhard Mall
- Wiesenbacher Str. 10, 69151 Neckargemünd, Germany
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12
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Endometriosis Stem Cells as a Possible Main Target for Carcinogenesis of Endometriosis-Associated Ovarian Cancer (EAOC). Cancers (Basel) 2022; 15:cancers15010111. [PMID: 36612107 PMCID: PMC9817684 DOI: 10.3390/cancers15010111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022] Open
Abstract
Endometriosis is a serious recurrent disease impairing the quality of life and fertility, and being a risk for some histologic types of ovarian cancer defined as endometriosis-associated ovarian cancers (EAOC). The presence of stem cells in the endometriotic foci could account for the proliferative, migrative and angiogenic activity of the lesions. Their phenotype and sources have been described. The similarly disturbed expression of several genes, miRNAs, galectins and chaperones has been observed both in endometriotic lesions and in ovarian or endometrial cancer. The importance of stem cells for nascence and sustain of malignant tumors is commonly appreciated. Although the proposed mechanisms promoting carcinogenesis leading from endometriosis into the EAOC are not completely known, they have been discussed in several articles. However, the role of endometriosis stem cells (ESCs) has not been discussed in this context. Here, we postulate that ESCs may be a main target for the carcinogenesis of EAOC and present the possible sequence of events resulting finally in the development of EAOC.
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13
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The Emerging Role of Menstrual-Blood-Derived Stem Cells in Endometriosis. Biomedicines 2022; 11:biomedicines11010039. [PMID: 36672546 PMCID: PMC9856091 DOI: 10.3390/biomedicines11010039] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022] Open
Abstract
The human endometrium has a complex cellular composition that is capable of promoting cyclic regeneration, where endometrial stem cells play a critical role. Menstrual blood-derived stem cells (MenSC) were first discovered in 2007 and described as exhibiting mesenchymal stem cell properties, setting them in the spotlight for endometriosis research. The stem cell theory for endometriosis pathogenesis, supported by the consensual mechanism of retrograde menstruation, highlights the recognized importance that MenSC have gained by potentially being directly related to the genesis, development and maintenance of ectopic endometriotic lesions. Meanwhile, the differences observed between MenSC in patients with endometriosis and in healthy women underlines the applicability of these cells as a putative biomarker for the early diagnosis of endometriosis, as well as for the development of targeted therapies. It is expected that in the near future MenSC will have the potential to change the way we manage this complex disease, once their long-term safety and effectiveness are assessed.
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14
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Altered differentiation of endometrial mesenchymal stromal fibroblasts is associated with endometriosis susceptibility. Commun Biol 2022; 5:600. [PMID: 35725766 PMCID: PMC9209414 DOI: 10.1038/s42003-022-03541-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 05/31/2022] [Indexed: 01/10/2023] Open
Abstract
Cellular development is tightly regulated as mature cells with aberrant functions may initiate pathogenic processes. The endometrium is a highly regenerative tissue, shedding and regenerating each month. Endometrial stromal fibroblasts are regenerated each cycle from mesenchymal stem cells and play a pivotal role in endometriosis, a disease characterised by endometrial cells that grow outside the uterus. Why the cells of some women are more capable of developing into endometriosis lesions is not clear. Using isolated, purified and cultured endometrial cells of mesenchymal origin from 19 women with (n = 10) and without (n = 9) endometriosis we analysed the transcriptome of 33,758 individual cells and compared these to clinical characteristics and in vitro growth profiles. We show purified mesenchymal cell cultures include a mix of mesenchymal stem cells and two endometrial stromal fibroblast subtypes with distinct transcriptomic signatures indicative of varied progression through the differentiation processes. The fibroblast subgroup characterised by incomplete differentiation was predominantly (81%) derived from women with endometriosis and exhibited an altered in vitro growth profile. These results uncover an inherent difference in endometrial cells of women with endometriosis and highlight the relevance of cellular differentiation and its potential to contribute to disease susceptibility. Comparing single cell transcriptome data to clinical characteristics and in vitro growth profiles uncovers a potential role for divergent mesenchymal-derived stromal fibroblast maturation in endometriosis susceptibility.
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15
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Cousins FL, Filby CE, Gargett CE. Endometrial Stem/Progenitor Cells–Their Role in Endometrial Repair and Regeneration. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 3:811537. [PMID: 36304009 PMCID: PMC9580754 DOI: 10.3389/frph.2021.811537] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/23/2021] [Indexed: 12/12/2022] Open
Abstract
The human endometrium is a remarkable tissue, undergoing ~450 cycles of proliferation, differentiation, shedding (menstruation), repair, and regeneration over a woman's reproductive lifespan. Post-menstrual repair is an extremely rapid and scar-free process, with re-epithelialization of the luminal epithelium completed within 48 h of initiation of shedding. Following menstruation, the functionalis grows from the residual basalis layer during the proliferative phase under the influence of rising circulating estrogen levels. The regenerative capacity of the endometrium is attributed to stem/progenitor cells which reside in both the epithelial and stromal cell compartments of the basalis layer. Finding a definitive marker for endometrial epithelial progenitors (eEPCs) has proven difficult. A number of different markers have been suggested as putative progenitor markers including, N-cadherin, SSEA-1, AXIN2, SOX-9 and ALDH1A1, some of which show functional stem cell activity in in vitro assays. Each marker has a unique location(s) in the glandular epithelium, which has led to the suggestion that a differentiation hierarchy exists, from the base of epithelial glands in the basalis to the luminal epithelium lining the functionalis, where epithelial cells express different combinations of markers as they differentiate and move up the gland into the functionalis away from the basalis niche. Perivascular endometrial mesenchymal stem cells (eMSCs) can be identified by co-expression of PDGFRβ and CD146 or by a single marker, SUSD2. This review will detail the known endometrial stem/progenitor markers; their identity, location and known interactions and hierarchy across the menstrual cycle, in particular post-menstrual repair and estrogen-driven regeneration, as well as their possible contributions to menstruation-related disorders such as endometriosis and regeneration-related disorder Asherman's syndrome. We will also highlight new techniques that allow for a greater understanding of stem/progenitor cells' role in repair and regeneration, including 3D organoids, 3D slice cultures and gene sequencing at the single cell level. Since mouse models are commonly used to study menstruation, repair and regeneration we will also detail the mouse stem/progenitor markers that have been investigated in vivo.
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Affiliation(s)
- Fiona L. Cousins
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
- *Correspondence: Fiona L. Cousins
| | - Caitlin E. Filby
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| | - Caroline E. Gargett
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
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16
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Salamonsen LA. Menstrual Fluid Factors Mediate Endometrial Repair. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:779979. [PMID: 36304016 PMCID: PMC9580638 DOI: 10.3389/frph.2021.779979] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
Menstruation is a process whereby the outer functionalis layer of the endometrium is shed each month in response to falling progesterone and estrogen levels in a non-conception cycle. Simultaneously with the tissue breakdown, the surface is re-epithelialized, protecting the wound from infection. Once menstruation is complete and estrogen levels start to rise, regeneration progresses throughout the proliferative phase of the cycle, to fully restore endometrial thickness. Endometrial repair is unique compared to tissue repair elsewhere in the adult, in that it is rapid, scar-free and occurs around 400 times during each modern woman's reproductive life. The shedding tissue and that undergoing repair is bathed in menstrual fluid, which contains live cells, cellular debris, fragments of extracellular matrix, activated leukocytes and their products, soluble cellular components and extracellular vesicles. Proteomic and other analyses have revealed some detail of these components. Menstrual fluid, along with a number of individual proteins enhances epithelial cell migration to cover the wound. This is shown in endometrial epithelial and keratinocyte cell culture models, in an ex vivo decellularized skin model and in pig wounds in vivo. Thus, the microenvironment provided by menstrual fluid, is likely responsible for the unique rapid and scar-free repair of this remarkable tissue. Insight gained from analysis of this fluid is likely to be of value not only for treating endometrial bleeding problems but also in providing potential new therapies for poorly repairing wounds such as those seen in the aged and in diabetics.
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17
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Comparison of Organoids from Menstrual Fluid and Hormone-Treated Endometrium: Novel Tools for Gynecological Research. J Pers Med 2021; 11:jpm11121314. [PMID: 34945786 PMCID: PMC8707872 DOI: 10.3390/jpm11121314] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/23/2021] [Accepted: 11/29/2021] [Indexed: 02/06/2023] Open
Abstract
Endometrial organoids (EMO) are an important tool for gynecological research but have been limited by generation from (1) invasively acquired tissues and thus advanced disease states and (2) from women who are not taking hormones, thus excluding 50% of the female reproductive-aged population. We sought to overcome these limitations by generating organoids from (1) menstrual fluid (MF; MFO) using a method that enables the concurrent isolation of menstrual fluid supernatant, stromal cells, and leukocytes and (2) from biopsies and hysterectomy samples from women taking hormonal medication (EMO-H). MF was collected in a menstrual cup for 4–6 h on day 2 of menstruation. Biopsies and hysterectomies were obtained during laparoscopic surgery. Organoids were generated from all sample types, with MFO and EMO-H showing similar cell proliferation rates, proportion and localization of the endometrial basalis epithelial marker, Stage Specific Embryonic Antigen-1 (SSEA-1), and gene expression profiles. Organoids from different disease states showed the moderate clustering of epithelial secretory and androgen receptor signaling genes. Thus, MFO and EMO-H are novel organoids that share similar features to EMO but with the advantage of (1) MFO being obtained non-invasively and (2) EMO-H being obtained from 50% of the women who are not currently being studied through standard methods. Thus, MFO and EMO-H are likely to prove to be invaluable tools for gynecological research, enabling the population-wide assessment of endometrial health and personalized medicine.
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18
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Oliveira FR, Casalechi M, Carneiro MM, de Ávila I, Dela Cruz C, Del Puerto HL, Camargos AF, Abrão MS, Reis FM. Immunolocalization of stem/progenitor cell biomarkers Oct-4, C-kit and Musashi-1 in endometriotic lesions. Mol Biol Rep 2021; 48:6863-6870. [PMID: 34468911 DOI: 10.1007/s11033-021-06685-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/23/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Human endometrium harbors stem/progenitor cells (SPCs) that may contribute to the establishment of endometriosis when seeded outside the uterus. Oct-4, C-kit and Musashi-1 are some of the many proteins used to characterize SPCs, but their association with endometriosis is uncertain. OBJECTIVE AND DESIGN In this study, specimens of normal endometrium (n = 12), eutopic endometrium from women with endometriosis (n = 9), superficial peritoneal endometriosis (SUP, n = 12) and deep endometriosis (DE, n = 13) lesions were evaluated for localization and intensity of immunostaining for Oct-4, C-kit and Musashi-1. RESULTS The three markers were abundantly expressed in normal endometrium, eutopic endometrium from endometriosis patients, SUP and DE specimens. Oct-4 and C-kit expression did not vary across groups as regards intensity or frequency. C-kit staining signal was seldom detected in vascular endothelium of normal or eutopic endometrium from endometriosis patients; however, it was positive in 67% of the SUP lesions and in 25% of the DE lesions (p = 0.042). Musashi-1 was expressed in some endometriotic glands as cell clusters, but its signal was similar between the four types of tissue (p = 0.971) CONCLUSION: The wide distribution of Oct-4, C-kit and Musashi-1 in endometria of patients with and without endometriosis and in SUP and DE endometriotic lesions suggests that these markers are not suitable for the in situ characterization of endometrial SPCs and should not be taken as surrogates for the study of SPCs in the pathogenesis of endometriosis.
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Affiliation(s)
- Flavia R Oliveira
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Maíra Casalechi
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Márcia M Carneiro
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Ivete de Ávila
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Cynthia Dela Cruz
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Helen L Del Puerto
- Department of Pathology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Aroldo F Camargos
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Maurício S Abrão
- Gynecologic Division, BP - A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Obstetrics and Gynecology Department, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Fernando M Reis
- Department of Obstetrics and Gynecology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
- Division of Human Reproduction, Department of Obstetrics and Gynecology, Hospital das Clínicas, UFMG, Av. Alfredo Balena, 110, 9˚ andar, Belo Horizonte, MG, 30130-100, Brazil.
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19
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Abstract
Uniquely among adult tissues, the human endometrium undergoes cyclical shedding, scar-free repair and regeneration during a woman's reproductive life. Therefore, it presents an outstanding model for study of such processes. This Review examines what is known of endometrial repair and regeneration following menstruation and parturition, including comparisons with wound repair and the influence of menstrual fluid components. We also discuss the contribution of endometrial stem/progenitor cells to endometrial regeneration, including the importance of the stem cell niche and stem cell-derived extracellular vesicles. Finally, we comment on the value of endometrial epithelial organoids to extend our understanding of endometrial development and regeneration, as well as therapeutic applications.
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Affiliation(s)
- Lois A Salamonsen
- Centre for Reproductive Health, Clayton, Victoria 3168, Australia.,Department of Molecular and Translational Science, Clayton, Victoria 3168, Australia
| | - Jennifer C Hutchison
- Centre for Reproductive Health, Clayton, Victoria 3168, Australia.,Department of Molecular and Translational Science, Clayton, Victoria 3168, Australia
| | - Caroline E Gargett
- Ritchie Centre, Hudson Institute of Medical Research, 25-31 Wright St, Clayton, Victoria 3168, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria 3168, Australia
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20
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Wyatt KA, Filby CE, Davies-Tuck ML, Suke SG, Evans J, Gargett CE. Menstrual fluid endometrial stem/progenitor cell and supernatant protein content: cyclical variation and indicative range. Hum Reprod 2021; 36:2215-2229. [PMID: 34173001 DOI: 10.1093/humrep/deab156] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/20/2021] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTION Does natural variation exist in the endometrial stem/progenitor cell and protein composition of menstrual fluid across menstrual cycles in women? SUMMARY ANSWER Limited variation exists in the percentage of some endometrial stem/progenitor cell types and abundance of selected proteins in menstrual fluid within and between a cohort of women. WHAT IS KNOWN ALREADY Menstrual fluid is a readily available biofluid that can represent the endometrial environment, containing endometrial stem/progenitor cells and protein factors. It is unknown whether there is natural variation in the cellular and protein content across menstrual cycles of individual women, which has significant implications for the use of menstrual fluid in research and clinical applications. STUDY DESIGN, SIZE, DURATION Menstrual fluid was collected from 11 non-pregnant females with regular menstrual cycles. Participants had not used hormonal medications in the previous 3 months. Participants collected menstrual fluid samples from up to five cycles using a silicone menstrual cup worn on Day 2 of menstrual bleeding. PARTICIPANTS/MATERIALS, SETTING, METHODS Menstrual fluid samples were centrifuged to separate soluble proteins and cells. Cells were depleted of red blood cells and CD45+ leucocytes. Menstrual fluid-derived endometrial stem/progenitor cells were characterized using multicolour flow cytometry including markers for endometrial stem/progenitor cells N-cadherin (NCAD) and stage-specific embryonic antigen-1 (SSEA-1) (for endometrial epithelial progenitor cells; eEPC), and sushi domain containing-2 (SUSD2) (for endometrial mesenchymal stem cells; eMSC). The clonogenicity of menstrual fluid-derived endometrial cells was assessed using colony forming unit assays. Menstrual fluid supernatant was analyzed using a custom magnetic Luminex assay. MAIN RESULTS AND THE ROLE OF CHANCE Endometrial stem/progenitor cells are shed in menstrual fluid and demonstrate clonogenic properties. The intraparticipant agreement for SUSD2+ menstrual fluid-derived eMSC (MF-eMSC), SSEA-1+ and NCAD+SSEA-1+ MF-eEPC, and stromal clonogenicity were moderate-good (intraclass correlation; ICC: 0.75, 0.56, 0.54 and 0.52, respectively), indicating limited variability across menstrual cycles. Endometrial inflammatory and repair proteins were detectable in menstrual fluid supernatant, with five of eight (63%) factors demonstrating moderate intraparticipant agreement (secretory leukocyte protein inhibitor (SLPI), lipocalin-2 (NGAL), lactoferrin, follistatin-like 1 (FSTL1), human epididymis protein-4 (HE4); ICC ranges: 0.57-0.69). Interparticipant variation was limited for healthy participants, with the exception of key outliers of which some had self-reported menstrual pathologies. LARGE SCALE DATA N/A. There are no OMICS or other data sets relevant to this study. LIMITATIONS, REASONS FOR CAUTION The main limitations to this research relate to the difficulty of obtaining menstrual fluid samples across multiple menstrual cycles in a consistent manner. Several participants could only donate across <3 cycles and the duration of wearing the menstrual cup varied between 4 and 6 h within and between women. Due to the limited sample size used in this study, wider studies involving multiple consecutive menstrual cycles and a larger cohort of women will be required to fully determine the normal range of endometrial stem/progenitor cell and supernatant protein content of menstrual fluid. Possibility for selection bias and true representation of the population of women should also be considered. WIDER IMPLICATIONS OF THE FINDINGS Menstrual fluid is a reliable source of endometrial stem/progenitor cells and related endometrial proteins with diagnostic potential. The present study indicates that a single menstrual sample may be sufficient in characterizing a variety of cellular and protein parameters across women's menstrual cycles. The results also demonstrate the potential of menstrual fluid for identifying endometrial and menstrual abnormalities in both research and clinical settings as a non-invasive method for assessing endometrial health. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by grants from the Australian National Health and Medical Research Council to C.E.G. (Senior Research Fellowship 1024298 and Investigator Fellowship 1173882) and to J.E. (project grant 1047756), the Monash IVF Research Foundation to C.E.G. and the Victorian Government's Operational Infrastructure Support Program. K.A.W., M.L.D.-T., S.G.S. and J.E. declare no conflicts of interest. C.E.G. reports grants from NHMRC, during the conduct of the study; grants from EndoFound USA, grants from Ferring Research Innovation, grants from United States Department of Defence, grants from Clue-Utopia Research Foundation, outside the submitted work. CEF reports grants from EndoFound USA, grants from Clue-Utopia Research Foundation, outside the submitted work.
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Affiliation(s)
- K A Wyatt
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, 3168 VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, 3168 VIC, Australia
| | - C E Filby
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, 3168 VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, 3168 VIC, Australia
| | - M L Davies-Tuck
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, 3168 VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, 3168 VIC, Australia
| | - S G Suke
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, 3168 VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, 3168 VIC, Australia
| | - J Evans
- Department of Obstetrics and Gynaecology, Monash University, Clayton, 3168 VIC, Australia.,Centre for Reproductive Health, Hudson Institute of Medical Research, Clayton, 3168 VIC, Australia
| | - C E Gargett
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, 3168 VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, 3168 VIC, Australia
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21
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Dorning A, Dhami P, Panir K, Hogg C, Park E, Ferguson GD, Hargrove D, Karras J, Horne AW, Greaves E. Bioluminescent imaging in induced mouse models of endometriosis reveals differences in four model variations. Dis Model Mech 2021; 14:dmm049070. [PMID: 34382636 PMCID: PMC8419713 DOI: 10.1242/dmm.049070] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/21/2021] [Indexed: 12/18/2022] Open
Abstract
Our understanding of the aetiology and pathophysiology of endometriosis remains limited. Disease modelling in the field is problematic as many versions of induced mouse models of endometriosis exist. We integrated bioluminescent imaging of 'lesions' generated using luciferase-expressing donor mice. We compared longitudinal bioluminescence and histology of lesions, sensory behaviour of mice with induced endometriosis and the impact of the gonadotropin-releasing hormone antagonist Cetrorelix on lesion regression and sensory behaviour. Four models of endometriosis were tested. We found that the nature of the donor uterine material was a key determinant of how chronic the lesions were, as well as their cellular composition. The severity of pain-like behaviour also varied across models. Although Cetrorelix significantly reduced lesion bioluminescence in all models, it had varying impacts on pain-like behaviour. Collectively, our results demonstrate key differences in the progression of the 'disease' across different mouse models of endometriosis. We propose that validation and testing in multiple models, each of which may be representative of the different subtypes/heterogeneity observed in women, should become a standard approach to discovery science in the field of endometriosis.
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Affiliation(s)
- Ashley Dorning
- Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Priya Dhami
- Centre for Early Life, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Kavita Panir
- Centre for Early Life, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Chloe Hogg
- Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Emma Park
- Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Gregory D. Ferguson
- Ferring Research Institute, 4245 Sorrento Valley Blvd, San Diego, CA 92121, USA
| | - Diane Hargrove
- Ferring Research Institute, 4245 Sorrento Valley Blvd, San Diego, CA 92121, USA
| | - James Karras
- Ferring Research Institute, 4245 Sorrento Valley Blvd, San Diego, CA 92121, USA
| | - Andrew W. Horne
- Medical Research Council Centre for Reproductive Health, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Erin Greaves
- Centre for Early Life, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
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